Automated caregiving device with prompting based on caregiver progress

ABSTRACT

An example of an automated external defibrillator (AED) includes a housing including a lid, printed graphical instructions indicating sequential steps for treatment of a patient with the AED, a speaker configured to provide audible messages associated at least in part with the printed graphical instructions, and defibrillation electrodes stored under the lid and configured for application during the treatment of the patient according to steps including a step of peeling a left electrode pad from a liner of the left electrode pad, a step of applying the left electrode pad to the patient, a step of peeling a right electrode pad from a liner of the right electrode pad, and a step of applying the right electrode pad to the patient.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation under 35 U.S.C. § 120 of U.S. patentapplication Ser. No. 16/034,402 filed on Jul. 13, 2018 which is acontinuation of U.S. patent application Ser. No. 15/592,240 filed on May11, 2017 and issued as U.S. Pat. No. 10,058,469 which is a continuationof U.S. patent application Ser. No. 15/162,581 filed on May 23, 2016 andissued as U.S. Pat. No. 9,693,917 which is a continuation of U.S. patentapplication Ser. No. 14/275,860, filed on May 12, 2014 and issued asU.S. Pat. No. 9,349,303, which is a continuation of U.S. patentapplication Ser. No. 13/477,335, filed on May 22, 2012 and issued asU.S. Pat. No. 8,725,254, which is a continuation of U.S. patentapplication Ser. No. 12/721,874, filed on Mar. 11, 2010 and issued asU.S. Pat. No. 8,204,589, which is a continuation of U.S. patentapplication Ser. No. 10/841,367, filed on May 7, 2004 and issued as U.S.Pat. No. 7,706,878. All subject matter set forth in the above referencedapplications is hereby incorporated by reference in its entirety intothe present application as if fully set forth herein.

TECHNICAL FIELD

This invention relates to devices for assisting caregivers in deliveringtherapy to a patient (e.g., automatic external defibrillators).

BACKGROUND

Resuscitation treatments for patients suffering from cardiac arrestgenerally include clearing and opening the patient's airway, providingrescue breathing for the patient, and applying chest compressions toprovide blood flow to the victim's heart, brain and other vital organs.If the patient has a shockable heart rhythm, resuscitation also mayinclude defibrillation therapy. The term basic life support (BLS)involves all the following elements: initial assessment; airwaymaintenance; expired air ventilation (rescue breathing); and chestcompression. When all these elements are combined, the termcardiopulmonary resuscitation (CPR) is used.

There are many different kinds of abnormal heart rhythms, some of whichcan be treated by defibrillation therapy (“shockable rhythms”) and somewhich cannot (non-shockable rhythms”). For example, most ECG rhythmsthat produce significant cardiac output are considered non-shockable(examples include normal sinus rhythms, certain bradycardias, and sinustachycardias). There are also several abnormal ECG rhythms that do notresult in significant cardiac output but are still considerednon-shockable, since defibrillation treatment is usually ineffectiveunder these conditions. Examples of these non-shockable rhythms includeasystole, electromechanical disassociation, and other pulselesselectrical activity. Although a patient cannot remain alive with thesenon-viable, non-shockable rhythms, applying shocks will not help convertthe rhythm. The primary examples of shockable rhythms, for which thecaregiver should perform defibrillation, include ventricularfibrillation, ventricular tachycardia, and ventricular flutter.

After using a defibrillator to apply one or more shocks to a patient whohas a shockable ECG rhythm, the patient may nevertheless remainunconscious, in a shockable or non-shockable, perfusing or non-perfusingrhythm. If a non-perfusing rhythm is present, the caregiver may thenresort to performing CPR for a period of time in order to providecontinuing blood flow and oxygen to the patient's heart, brain and othervital organs. If a shockable rhythm continues to exist or developsduring the delivery of CPR, further defibrillation attempts may beundertaken following this period of cardiopulmonary resuscitation. Aslong as the patient remains unconscious and without effectivecirculation, the caregiver can alternate between use of thedefibrillator (for analyzing the electrical rhythm and possibly applyinga shock) and performing cardio-pulmonary resuscitation (CPR). CPRgenerally involves a repeating pattern of five or fifteen chestcompressions followed by a pause during which two rescue breaths aregiven.

Defibrillation can be performed using an AED. The American HeartAssociation, European Resuscitation Council, and other similar agenciesprovide protocols for the treatment of victims of cardiac arrest thatinclude the use of AEDs. These protocols define a sequence of steps tobe followed in accessing the victim's condition and determining theappropriate treatments to be delivered during resuscitation. Caregiverswho may be required to use an AED are trained to follow these protocols.

Most automatic external defibrillators are actually semi-automaticexternal defibrillators (SAEDs), which require the caregiver to press astart or analyze button, after which the defibrillator analyzes thepatient's ECG rhythm and advises the caregiver to provide a shock to thepatient if the electrical rhythm is shockable. The caregiver is thenresponsible for pressing a control button to deliver the shock.Following shock delivery, the SAED may reanalyze the patient's ECGrhythm, automatically or manually, and advise additional shocks orinstruct the caregiver to check the patient for signs of circulation(indicating that the defibrillation treatment was successful or that therhythm is non-shockable) and to begin CPR if circulation has not beenrestored by the defibrillation attempts. Fully automatic externaldefibrillators, on the other hand, do not wait for user interventionbefore applying defibrillation shocks. As used below, automatic externaldefibrillators (AED) include semi-automatic external defibrillators(SAED).

Both types of defibrillators typically provide an auditory “stand clear”warning before beginning ECG analysis and/or the application of eachshock. The caregiver is then expected to stand clear of the patient(i.e., stop any physical contact with the patient) and may be requiredto press a button to deliver the shock. The controls for automaticexternal defibrillators are typically located on a resuscitation devicehousing.

AEDs are typically used by trained medical or paramedic caregivers, suchas physicians, nurses, emergency medical technicians, fire departmentpersonnel, and police officers. The ready availability of on-site AEDsand caregivers trained to operate them is important because a patient'schances of survival from cardiac arrest decrease by approximately 10%for each minute of delay between occurrence of the arrest and thedelivery of defibrillation therapy.

Trained lay caregivers are a new group of AED operators. For example,spouses of heart attack victims may become trained as lay caregivers.Lay caregivers rarely have opportunities to defibrillate or deliver CPR,and thus they can be easily intimidated by an AED during a medicalemergency. Consequently, such lay providers may be reluctant to purchaseor use AEDs when needed, or might tend to wait for an ambulance toarrive rather than use an available AED, out of concern that the layprovider might do something wrong.

Some trained medical providers, e.g., specialists such as obstetricians,dermatologists, and family care practitioners, also rarely have theopportunity to perform CPR and/or defibrillate, and thus may be uneasyabout doing so. Concerns about competence are exacerbated if training isinfrequent, leading the caregiver to worry that he or she may not beable to remember all of the recommended resuscitation protocol stepsand/or their correct sequence.

Similarly, both medical and lay caregivers may be hesitant to provideCPR and rescue breathing, or may be unsure when these steps should beperformed, particularly if their training is infrequent and they rarelyhave the opportunity to use it.

It is well known to those skilled in the art, and has been shown in anumber of studies, that CPR is a complex task with both poor initiallearning as well as poor skill retention, with trainees often losing 80%of their initial skills within 6-9 months. It has thus been the objectof a variety of prior art to attempt to improve on this disadvantageouscondition. Aids in the performance of chest compressions are describedin U.S. Pat. Nos. 4,019,501, 4,077,400, 4,095,590, 5,496,257, 6,125,299,and 6,306,107, 6,390,996. U.S. Pat. Nos. 4,588,383, 5,662,690 5,913,685,4,863,385 describe CPR prompting systems. AEDs have always includedvoice prompts as well as graphical instructions on flip charts orplacards since the earliest commercial versions in 1974 to provide bothcorrect timing and sequence for the complex series of actions requiredof the rescuer (caregiver) as well as placement of the defibrillationelectrodes. U.S. patent application Ser. No. 09/952,834 and U.S. Pat.Nos. 6,334,070 and 6,356,785 describe defibrillators with an increasedlevel of prompting including visual prompts either in the form ofgraphical instructions presented on a CRT or on printed labels withbacklighting or emissive indicia such as light emitting diodes. AEDssince the 1970s have used the impedance measured between thedefibrillation electrodes to determine the state of the AED as well asappropriate messages to deliver to the rescuer (e.g. “Attach Electrodes”if the initial prompts on the unit have been delivered and the impedanceremains greater than some specified threshold) or to determine if thereis excessive patient motion (as in U.S. Pat. No. 4,610,254.) U.S. Pat.No. 5,700,281 describes a device which uses the impedance of theelectrodes to determine the state of the AED for delivering messagessuch as “Attach Electrodes”. Enhanced prompting disclosed in thesepatents provides some benefit to the rescuer in improved adherence tothe complex protocol required of them to successfully revive a cardiacarrest patient, but the enhanced prompting is usually not sufficient inreal world situations. U.S. Pat. Nos. 5,662,690 and 6,356,785 (and thecommercially available OnSite defibrillator) attempts to improveprompting by providing a rescuer-accessible “Help” key that initiatesmore detailed prompting in cases in which the rescuer or test subject isconfused. But testing has shown that with the heightened level ofanxiety that accompanies a real cardiac arrest, rescuers rarely rememberto press such a Help key. Even notifying the rescuer at the beginning ofthe protocol to press the Help key does not help a confused rescuerpress the Help key. Furthermore, even if the Help key is pressed, it isnecessary to have the rescuer work through a series of user interfaceinteractions via a touchscreen, soft keys or other input means, for thehelp software to determine at which step the rescuer is in need ofadditional instructions. Putting the user through these interactionswith the help software detracts from the rescuer's ability to provideaid to the patient, and thus delays delivery of therapy.

AEDs have also been solely focused on defibrillation, which, while itprovides the best treatment for ventricular fibrillation and certaintachycardias, is of no therapeutic benefit for the 60% of the cardiacarrest patients presenting in pulseless electrical activity (PEA) orasystole. As AEDs are becoming more prevalent in the home, there arealso a host of other health problems that occur such as first aid aswell as incidents related to chronic conditions such as asthma, diabetesor cardiac-related conditions for which the AED is of no benefit.

SUMMARY

In a first aspect, the invention features a device for assisting acaregiver in delivering therapy to a patient, the device comprising auser interface configured to deliver prompts to a caregiver to assistthe caregiver in delivering therapy to a patient; at least one sensorconfigured to detect the caregiver's progress in delivering the therapy,wherein the sensor is other than an electrode in an electrical contactwith the body; a memory in which a plurality of different prompts arestored; a processor configured to determine which of the differentprompts should be selected for delivery based on the progress detectedby the sensor.

Preferred implementations of this aspect of the invention mayincorporate one or more of the following: There may be a plurality ofsensors configured to detect the caregiver's progress in delivering thetherapy, wherein each of the plurality of sensor is other than anelectrode connected to the body. The processor may be configured to varythe time at which prompts are delivered based on the progress detectedby the sensor. One or more additional sensors may be configured todetect the caregiver's progress in delivering the therapy, wherein theone or more additional sensors comprise an electrode in electricalcontact with the body. The at least one sensor may comprise aphotoelectric sensor on the electrode for assisting in detection ofwhether the electrode has been applied to clothing. The therapy maycomprise a series of steps in a protocol, and at least two sensors maybe configured to detect whether at least two of the steps in theprotocol have been successfully completed. The processor may select aseries of more detailed prompts for delivery to a user when progress isslower than a predetermined pace. The processor may be configured toslow down the rate at which prompts are delivered when progress isslower than a predetermined pace. The processor may be configured tochoose from among at least three rates at which prompts are delivered,and the choice is based at least in part on the progress detected by thesensor. The progress detected by the sensors may comprise whether a stepin the protocol has been initiated and whether the step has beencompleted. The user interface may deliver at least some of the promptsas oral instructions to be heard by the caregiver. The user interfacemay deliver at least some of the prompts as visual instructions to beseen by the caregiver. The user interface may comprise an electronicdisplay. The electronic display may provide a series of images. The userinterface may comprise a series of printed pages. The device may furthercomprise one or more detectors configured to detect which page of theseries of pages is being viewed by the caregiver. The detectors maycomprise magnetic sensors that detect the presence of magnetic memberssupported by the pages. The processor may be configured to provideprompts with a first level of detail when progress is occurring at orfaster than a predetermined rate, and with a second level of detail morespecific than the first level of detail when progress is occurring at orslower than the predetermined rate. The sensor may be configured todetect whether the caregiver has made a predetermined error indelivering the therapy, and the processor may be configured to deliverone or more prompts designed to assist the user in correcting thepredetermined error. The progress detected by the sensors may comprisewhether a step in the protocol has been initiated and whether the stephas been completed, and the processor may be configured to pause indelivery of prompts if a step has been initiated but not completed, andno predetermined error associated with the step has been detected. Thedevice may be configured to assist a caregiver in delivering therapy forone or more cardiac malfunctions. The device may be configured to assista caregiver in delivering therapy for one or more cardiac malfunctions.The device may be configured to assist a caregiver in delivering chestcompressions. The device may be configured to assist a caregiver indelivering CPR. The device may be configured to assist a caregiver indelivering an electrical stimulus to the heart. The electrical stimulusmay include defibrillation. The electrical stimulus may include pacing.

The device may comprise a defibrillator; and electrodes constructed toacquire data, indicative of the heart rhythm of the patient andindicative of whether the electrodes are properly placed on the patientand to deliver a defibrillating shock if appropriate. The device mayfurther comprise on a portion of a housing for the device, a series ofgraphics configured to prompt a caregiver to perform a sequence of stepsappropriate for treating a victim of suspected cardiac arrest Thegraphics may include a picture configured to prompt the caregiver tocheck the patient for responsiveness. The graphics may include a pictureconfigured to prompt the caregiver to call for emergency assistance. Thegraphics may include a picture configured to prompt the caregiver toopen the patient's airway. The graphics may include a picture configuredto prompt the caregiver on how to open the patient's airway. Thegraphics may include a picture configured to prompt the caregiver tocheck the patient for signs of circulation. The graphics may include apicture configured to prompt the caregiver to attach the electrodes tothe patient. The graphics may include a picture configured to prompt thecaregiver on where the electrodes should be attached. The graphics mayinclude a picture configured to prompt the caregiver to stand clear ofthe patient. The graphics may include a picture configured to prompt thecaregiver to press a treatment button to cause the device to administera defibrillating shock. The graphics may include a picture configured toprompt the caregiver to perform CPR. The graphics may include one ormore pictures illustrating procedures for chest compressions and rescuebreathing. The pictures may include a heart symbol indicating thelocation of the treatment button. The device may include a treatmentbutton configured to be pressed by the caregiver to cause thedefibrillator to administer a defibrillating shock. The device mayfurther include a light source associated with each of the graphics inthe series. The device may comprise electronics configured tosequentially illuminate the light sources. The graphics may include oneor more pictures selected from the group consisting of: a pictureconfigured to prompt the caregiver to check the patient forresponsiveness; a picture configured to prompt the caregiver to call foremergency assistance; a picture configured to prompt the caregiver toopen the patient's airway; a picture configured to prompt the caregiverto check the patient for signs of circulation; a picture configured toprompt the caregiver to attach the electrodes to the patient; a pictureconfigured to prompt the caregiver to stand clear of the patient; and apicture configured to prompt the caregiver to perform CPR. The graphicsmay include a picture configured to prompt the caregiver to press atreatment button to cause the defibrillator to administer adefibrillating shock. The graphics may include one or more picturesselected from the group consisting of: a picture configured to promptthe caregiver to check the patient for responsiveness; a pictureconfigured to prompt the caregiver to call for emergency assistance; apicture configured to prompt the caregiver to open the patient's airway;a picture configured to prompt the caregiver to check the patient forsigns of circulation; a picture configured to prompt the caregiver toattach the electrodes to the patient; a picture configured to prompt thecaregiver to stand clear of the patient; and a picture configured toprompt the caregiver to perform CPR. The light sources may compriseLEDs. The audio prompts may be associated with the series of graphicsand are given sequentially to guide the caregiver through the sequenceof steps. The device may further comprise electronics configured tosequentially illuminate the light sources, wherein the audio prompts areassociated with the series of graphics and with the sequentialillumination of the light sources, to guide the caregiver through thesequence of steps. The device may further comprise electronicsconfigured to measure the time elapsed from the time at which thecaregiver turned the power on to activate the defibrillator, and atleast some of the audio prompts are timed to occur based on the elapsedtime. At least some of the graphics may be provided on a cover portionof the defibrillator device housing. At least some of the graphics maybe provided on the outside of the cover portion of the device. Thegraphics on the cover portion may include a picture indicating that thecover should be removed from the device. The cover portion may include aspace provided for local emergency information. The cover portion mayinclude a window behind which a card bearing local emergency informationcan be placed. At least some of the graphics may be provided in the formof backlit, translucent images. At least some of the graphics may beprovided in the form of a decal. The device may further comprisebuttons, associated with at least some of the graphics, which, whenpressed, cause more detailed audio prompts related to the associatedgraphic to be output by the device. The graphics may include one or morepictures indicating that the caregiver should place a passive airwaysupport under the shoulders of the patient. The graphics may include apicture configured to prompt the caregiver to check to see if thepatient is breathing. The prompts and graphical interface may illustratethe entire sequence of resuscitation activities that are recommended bythe American Heart Association. The prompts may include instructions forperforming first aid. The device may comprise a cover to the devicewhose removal the processor is capable of detecting; and a series ofbound pages on the face of the device under the cover with one or moresensors for determining to which page the bound pages have been turned.The device may further comprise a portion of the device usedspecifically for storage of items commonly used in the course ofproviding aid such as bandaids, bandages, splints, antiseptic. Thestorage area may be partitioned into individual wells in which each ofthe items is stored and a detection means may be provided fordetermining which, if any, of the items has been removed by the user.Photoelectric sensors may be provided in each of the wells. The promptsand graphical interface may illustrate the Red Cross First Aid treatmentprotocols.

The device may include a cover whose removal the processor is capable ofdetecting; a defibrillator for delivering defibrillation shocks;electrodes configured to be attached to a patient, to acquire dataindicative of the patient's heart rhythm and to deliver a defibrillatingshock if appropriate; a storage area for said electrodes; and at leastone sensor for determining if the electrodes have been removed from thestorage area by the user. The storage area may be a compartment that ispart of the housing of the device. The storage area may be a packageremovable from the housing of the device. The cover may be shaped foruse as a neck rest for maintaining the patient's airway in the necessaryopen condition during CPR. A detection means may be provided fordetermining if the patient's head is correctly located on the coverwhile it is being used as a neck rest. The detection means may beprovided by a pressure sensor. The detection means may be provided by aphotoelectric sensor.

The device may further comprise a decision making system provided by adistributed network may comprise a remotely located human expert, anelectronic processor in the device, and an electronic communication linkbetween the human and electronic processor. The information transmittedover the communication link may be both voice and digital data. The datamay be bi-directional. The digital data may contain information aboutthe device's location and the status of the device. The device may becapable of being remotely controlled by the human expert. The electronicprocessor may revert to providing internally generated responsivefeedback prompts if the communication link is lost to the remotelylocated human expert. The device may further comprise a decision-makingsystem comprising circuitry and an electronic processor located in thedevice. The device may further comprise a decision making systemprovided by a distributed network comprising a remotely locatedelectronic processing system, a local electronic processing system inthe device and an electronic communication link between the remote andlocal electronic processing system. The device may further comprise aprocessing system that measures and records the times required for auser to complete a sequence of steps and/or sub-steps in a protocol,and, based on the measured times adjusting the rate of the promptingdelivered by the processor and user interface. The adjusting may bebased on a comparison of the measured times with a set of stored values.The device may comprise decision-making circuitry for evaluating thedifference between the measured times and the set of stored values. Thedevice may further comprise elements for correctly identifying a set ofvoice commands delivered by the user and performing a set of actions inresponse to those user voice commands.

In a second aspect, the invention features an automatic externaldefibrillator for assisting a caregiver in delivering resuscitationtherapy to a patient, the defibrillator comprising a memory in which aplurality of different prompts are stored; a processor configured todetermine which of the different prompts should be selected fordelivery; a user interface configured to deliver the selected prompts toa caregiver to assist the caregiver in delivering therapy to a patient,wherein the user interface comprises a series of printed pages and oneor more detectors configured to detect which page of the series of pagesis being viewed by the caregiver.

Preferred implementations of this aspect of the invention mayincorporate one or more of the following. Detectors may comprisemagnetic sensors that detect the presence of magnetic members supportedby the pages.

Among the many advantages of the invention (some of which may beachieved only in some of its various aspects and implementations) arethat the invention provides a more comprehensive and effective systemfor prompting users in the delivery of care for first aid, chronichealth problems as well as cardiac arrest.

The invention can provide the further benefit that a device canintelligently vary the amount of detail to provide in prompts to thecaregiver. In currently available devices, the prompting has beenoptimized for the average user, and this is both frustrating andobstructive for the expert user; the more detailed prompting is notneeded by the expert user and actually delays delivery of treatment. Theinvention can eliminate the need for this compromise, by intelligentlydelivering prompts needed by the particular user.

Other features and advantages of the invention will be apparent from thedescription and drawings, and from the claims.

DESCRIPTION OF DRAWINGS

FIG. 1 is a perspective view of an AED with its cover on.

FIG. 2 is a perspective view of the AED of FIG. 1 with the coverremoved.

FIG. 3 is a block diagram of the AED.

FIG. 4 is a plan view of the graphical interface decal used on the coverof the AED of FIG. 1.

FIG. 5 is a plan view of the graphical interface decal used on thedevice housing of the AED of FIG. 1, as shown in FIG. 2.

FIG. 6a-6e are flow charts indicating audio prompts provided during useof the AED of FIG. 1 and steps to be performed by the caregiver inresponse to the graphical and audio prompts.

FIGS. 7a and 7b list the audio prompts used in the flowcharts shown inFIGS. 6a -6 e.

FIG. 8 is an exploded perspective view of the cover and housing.

FIG. 9 is a side plan view of the cover indicating angle ‘A’.

FIGS. 10a and 10b are side views of a patient with and without the coverplaced beneath the shoulders, to show the effect on the patient's airwayof placing the cover beneath the shoulders.

FIG. 11 is a plan view of a decal providing graphical instructions onthe cover for placing the cover under a patient's shoulders.

FIG. 12 shows an integrated electrode pad.

FIG. 13 is another view of an electrode pad.

FIG. 14 is an isometric view of an electrode well along one side of thehousing.

FIG. 15 is a schematic of the electronics contained in the integratedelectrode pad of FIG. 12.

FIG. 16 is an isometric view of a first-aid kit implementation.

DETAILED DESCRIPTION

There are a great many possible implementations of the invention, toomany to describe herein. Some possible implementations that arepresently preferred are described below. It cannot be emphasized toostrongly, however, that these are descriptions of implementations of theinvention, and not descriptions of the invention, which is not limitedto the detailed implementations described in this section but isdescribed in broader terms in the claims.

The terms “caregiver”, “rescuer” and “user” are used interchangeably andrefer to the operator of the device providing care to the patient.

Referring to FIGS. 1 and 2, an automated external defibrillator (AED) 10includes a removable cover 12 and a device housing 14. The defibrillator10 is shown with cover 12 removed in FIG. 2. An electrode assembly 16(or a pair of separate electrodes) is connected to the device housing 14by a cable 18. Electrode assembly 16 is stored under cover 12 when thedefibrillator is not in use.

Referring to FIG. 3, the AED includes circuitry and software 20 forprocessing, a user interface 21 including such elements as a graphical22 or text display 23 or an audio output such as a speaker 24, andcircuitry and/or software 25 for detecting a caregiver's progress indelivering therapy—e.g., detecting whether one or more of a series ofsteps in a protocol has been completed successfully In some preferredimplementations, the detecting also includes the ability to determineboth whether a particular step has been initiated by a user andadditionally whether that particular step has been successfullycompleted by a user. Based on usability studies in either simulated oractual use, common user errors are determined and specific detectionmeans are provided for determining if the most prevalent errors haveoccurred.

If it is determined that the current step in the protocol has not beencompleted, then the processor will pause the currently-scheduledsequence of instructions. If, for instance, it has been determined thata particular step has been initiated but not completed, but none of thecommon errors has occurred subsequent to initiation of the particularstep, then the processor may simply provide a pause while waiting forthe user to complete the step. If, after waiting for a predeterminedperiod of time based on prior usability tests, there has been nodetection of the step completion, the processor may initiate a moredetailed set of prompts, typically at a slower sequence rate, describingthe individual sub-steps that comprise a particular step. If one of thecommon errors is detected while waiting for completion of the step, theprocessor may initiate a sequence of instructions to correct the user'sfaulty performance.

Device housing 14 includes a power button 15 and a status indicator 17.Status indicator 17 indicates to the caregiver whether the defibrillatoris ready to use.

The cover 12 includes a cover decal 30 (FIG. 1) including a logo 31 anda series of graphics 32, 34 and 36. Logo 31 may provide informationconcerning the manufacturer of the device and that the device is adefibrillator (e.g., “ZOLL AED”, as shown in FIG. 1, indicating that thedevice is a Semi-Automatic External Defibrillator available from ZOLL®Medical Corp.). Graphics 32, 34 and 36 lead the caregiver through theinitial stages of a cardiac resuscitation sequence as outlined in theAHA's AED treatment algorithm for Emergency Cardiac Care pending arrivalof emergency medical personnel. (See “Guidelines 2000 forCardiopulmonary Resuscitation and Emergency Cardiovascular Care.Supplement to Circulation,” Volume 102, Number 8, Aug. 22, 2000, pp.I-67.) Thus, graphic 32, showing the caregiver and patient, indicatesthat the caregiver should first check the patient for responsiveness,e.g., by shaking the patient gently and asking if the patient is okay.Next, graphic 34, showing a telephone and an emergency vehicle,indicates that the caregiver should call for emergency assistance priorto administering resuscitation. Finally, graphic 36 indicates that afterthese steps have been performed the caregiver should remove the cover 12of the defibrillator, remove the electrode assembly 16 stored under thelid, and turn the power on by depressing button 15. The graphics arearranged in clockwise order, with the first step in the upper left,since this is the order most caregivers would intuitively follow.However, in this case the order in which the caregiver performs thesteps is not critical, and thus for simplicity no other indication ofthe order of steps is provided.

The device housing includes a device housing decal 40, shown in FIG. 2.The graphics are configured to lead the caregiver through the entireresuscitation sequence, as will be explained below with reference toFIGS. 6a-6e . Decal 40 also includes a center graphic 50, which includesrepresentations of a hand and a heart. Center graphic 50 overlies atreatment button which, when depressed, causes the defibrillator todeliver a defibrillating shock to the electrode assembly 16.

Each of the graphics on device housing decal 40 is accompanied by alight source that can be temporarily illuminated to indicate that theilluminated step should be performed at that particular time. Theselight sources guide the caregiver, step-by-step, through theresuscitation sequence, indicating which graphic should be viewed ateach point in time during resuscitation.

The light source for each of the graphics 42-50 is preferably anadjacent LED (LEDs 56, FIG. 2). The heart 54 may be translucent andbacklit by a light source in the device housing (not shown).Alternatively, the heart may include an adjacent LED (not shown) and/orthe hand 52 may include an LED 57 as shown. Programmable electronicswithin the device housing 14 are used to determine when each of thelight sources should be illuminated.

In some preferred implementations, a liquid crystal display 51 is usedto provide the more detailed graphical prompts when a user is unable tocomplete the rescue sequence on their own. In these implementations, thepurpose of the printed graphics is to provide a more general indicationof the current step in the overall sequence, e.g. airway graphics 44provides an indication that the rescuer should be performing the “OpenAirway. Check for Breathing.” sub-sequence, but may not provide adetailed enough description for someone who has forgotten the correctactions to perform. In an alternative embodiment, the graphicalinstructions may be provided by a larger version of the liquid crystaldisplay (LCD) 51 whereby the LED-lit printed instructions are eliminatedor removed and most or all of the graphical instructions are provided bythe LCD 30. In this case, the LCD 51 will automatically show the moredetailed instructions when it determines that the user is unable toproperly perform the action.

The programmable electronics may also provide audio prompts, timed tocoincide with the illumination of the light sources and display ofimages on the liquid crystal display 51, as will also be discussed belowwith reference to FIGS. 6a and 6 e.

The cover 12 is constructed to be positioned under a patient's neck andshoulders, as shown in FIGS. 10a and 10b , to support the patient'sshoulders and neck in a way that helps to maintain his airway in an openposition, i.e., maintaining the patient in the head tilt-chin liftposition. The cover is preferably formed of a relatively rigid plasticwith sufficient wall thickness to provide firm support duringresuscitation. Suitable plastics include, for example, ABS,polypropylene, and ABS/polypropylene blends.

Prior to administering treatment for cardiac arrest, the caregivershould make sure that the patient's airway is clear and unobstructed, toassure passage of air into the lungs. To prevent obstruction of theairway by the patient's tongue and epiglottis (e.g., as shown in FIG.10a ), it is desirable that the patient be put in a position in whichthe neck is supported in an elevated position with the head tilted backand down. Positioning the patient in this manner is referred to in theAmerican Heart Association Guidelines for Cardiopulmonary Resuscitationand Emergency Cardiovascular Care as the “head tilt-chin lift maneuver.”The head tilt-chin lift position provides a relatively straight, openairway to the lungs through the mouth and trachea. However, it may bedifficult to maintain the patient in this position during emergencytreatment.

The cover 12 has an upper surface 24 that is inclined at an angle A(FIG. 9a ) of from about 10 to 25 degrees, e.g., 15 to 20 degrees, so asto lift the patient's shoulders and thereby cause the patient's head totilt back. The upper surface 24 is smoothly curved to facilitatepositioning of the patient. A curved surface, e.g., having a radius ofcurvature of from about 20 to 30 inches (i.e., about 51 to 76 cm)generally provides better positioning than a flat surface. At itshighest point, the cover 12 has a height H (FIG. 9) of from about 7.5 to10 cm. To accommodate the width of most patients' shoulders, the cover12 preferably has a width of at least 6 inches, e.g., from about 6 to 10inches (i.e., about 15-25 cm). If the cover 12 is not wide enough, thepatient's neck and shoulders may move around during chest compressions,reducing the effectiveness of the device. The edge of the cover may alsoinclude a lip 11 (FIG. 9) or gasket (not shown) to prevent water fromentering the housing when the cover is in place. The positions shown inFIGS. 10a and 10b (a patient in the head lift-chin tilt position and apatient with a closed airway) are also shown in the AHA Guidelines forCardiopulmonary Resuscitation and Emergency Cardiovascular Care, Aug.22, 2000, p. I-32, FIGS. 7 and 8.

The cover 12 is provided with one or more sensors for determining if thepatient's shoulders have been properly positioned on the cover 12.Referring to FIG. 8, two photoelectric sensors 156, 157 are used todetermine if the cover has been placed underneath the patient's back.The sensors 156, 157 are located along the acute edge of the cover 12,with one facing inward and one facing outward with the cable 155providing both power to the sensors 156, 157 as well as detection of thesensor output. If the cover 12 is upside down, the inner sensor 156 willmeasure a higher light level than the outer sensor 157; if the cover hasbeen placed with the acute edge facing toward the top of the patient'shead, then the outer sensor 157 will measure higher than the innersensor 156 and will also exceed a pre-specified level. In the case of aproperly positioned cover, both inner 156 and outer sensor 157 outputswill be below a pre-specified level. In another embodiment, thedetections means is provided by a pressure sensor 158 located underneaththe cover decal. Referring to FIG. 6c , if the processing means 20detects that the cover is upside down, it will cause an audible promptto be delivered to the user that is more detailed than the originalprompt. The processing means 20 will also slow down the rate of speechof the audio prompts. If the cover is still upside down after apredetermined period of time, the processing means 20 will deliver aneven more detailed message on how to properly place the cover. If, afterthree attempts to get the user to properly position the cover 12, theprocessing means 20 will deliver the next audio prompt without furtherwaiting for proper placement of the cover 12.

In the preferred embodiment, the defibrillator includes communicationcapability such as cell phone, global positioning system (GPS) orsimpler wireless phone capability. Preferably, both cell phone and GPSare included in the device. The cell phone is preconfigured toautomatically dial the Emergency Response Center (ERC) in the communityin which it is located such as “911” in much of the United States. Thecell phone service is chosen which is able to provide voice, data, aswell as GPS capability. Thus in response to a command by the device to“Call 911 by Pressing the Phone button”, the device automatically dials911 and the built-in speaker 360 and microphone 159 on the devicefunction to provide speakerphone capability. If a connection issuccessfully made to the emergency response center, the device transmitsits exact location based on its GPS capability and also can transmit tothe response center the status of the defibrillator. In more advancedmodes, the emergency response center can remotely control the operationof the defibrillator via the bi-directional data capability. When aconnection is made to the ERC and emergency response personnel (ERP),the automatic voice prompting of the defibrillator can be remotelyde-activated by the ERP so as not to distract the rescuer from theinstructions given by the ERP. While coaching the rescuer via thespeakerphone capability in the defibrillator, the ERP can utilize theresponsive feedback prompting functionality of the device to providemore accurate coaching of the rescuer. It is well known, however, thatcell phone and other wireless communication methods are not especiallyreliable even under the best circumstances, and are often completelyunavailable in industrial facilities, basements, etc., thus it isimportant to provide a means of automatically reverting to the modewherein the device provides all responsive feedback prompts to the userwhen the processor detects that the communication link has been lost.Additional prompts will also be provided to the user to assuage anyconcern they might have that the connection to the human expert has beenlost (e.g. “Communication has been temporarily lost to 911 personnel.Don't worry. This AED is able to perform all steps and help you throughthis procedure.”). When a communication link has been lost, the devicewill preferably automatically begin recording all device and patientstatus as well as all audio received by the built-in microphone. If thecommunication link is subsequently reacquired, the device willpreferably automatically transmit the complete event, including patient,device and audio data, acquired during the time communication was notavailable, providing ERP valuable data to help in their medicaldecision-making. The ERP may remotely control the defibrillator via abi-directional communication link that transmits both voice and data.

In another embodiment, a remote computer located at the ERC, that ismore capable than the processor in the device may provide the remotedecision-making capability. The remote computer would run artificialintelligence software utilizing such techniques, e.g., as fuzzy logic,neural nets and intelligent agents to provide prompting to the user.

FIG. 6a illustrates, in flow chart form, the default graphical and audioprompts provided by the device for a caregiver performing resuscitation.The prompts shown in the figure do not include responsive feedbackprompts by the device that provide more detailed instructions dependingon whether particular sequences have been successfully completed by thecaregiver. The text in boxes indicates steps performed by the caregiver.The text in caption balloons, with ear symbols, indicates audio promptsgenerated by the defibrillator. FIGS. 6b-6e provide flowcharts of moredetailed responsive feedback prompts (the content of which are shown inFIGS. 7a, 7b ) that may be provided to supplement the steps of callingfor help, open airway/check for breathing, and defibrillation electrodeapplication.

Thus, when a person collapses and a caregiver suspects that the personis in cardiac arrest 100 (FIG. 6a ), the caregiver first gets thedefibrillator and turns the power on 102. If the unit passes itsinternal self-tests, and is ready for use, this will be indicated byindicator 17, as discussed above. Next, the defibrillator prompts thecaregiver with an introductory audio message, e.g., “Stay calm. Listencarefully” (audio prompt 104).

Shortly thereafter, the defibrillator will prompt the caregiver with anaudio message indicating that the caregiver should check the patient forresponsiveness (audio prompt 106). Simultaneously, the LED adjacentgraphic 42 will light up, directing the caregiver to look at thisgraphic. Graphic 42 will indicate to the caregiver that she should shout“are you OK?” and shake the person (step 108) in order to determinewhether the patient is unconscious or not.

After a suitable period of time has elapsed (e.g., 2 seconds), if thecaregiver has not turned the defibrillator power off (as would occur ifthe patient were responsive), the defibrillator will give an audioprompt indicating that the caregiver should call for help (audio prompt110). Simultaneously, the LED adjacent graphic 42 will turn off and theLED adjacent graphic 43 will light up, directing the caregiver'sattention to graphic 43. Graphic 43 will remind the caregiver to callemergency personnel (step 112), if the caregiver has not already doneso.

After a suitable interval has been allowed for the caregiver to performstep 112 (e.g., 2 seconds since audio prompt 110) the defibrillator willgive an audio prompt indicating that the caregiver should open thepatient's airway and check whether the patient is breathing (audioprompt 114). The LED adjacent graphic 43 will turn off, and the LEDadjacent graphic 44 will light up, directing the caregiver's attentionto graphic 44, which shows the proper procedure for opening a patient'sairway. This will lead the caregiver to lift the patient's chin and tiltthe patient's head back (step 116). The caregiver may also position anairway support device under the patient's neck and shoulders, ifdesired, as discussed below with reference to FIGS. 10a, 10b . Thecaregiver will then check to determine whether the patient is breathing.

After a suitable interval (e.g., 15 seconds since audio prompt 114), thedefibrillator will give an audio prompt indicating that the caregivershould check for signs of circulation (audio prompt 118), the LEDadjacent graphic 44 will turn off, and the LED adjacent graphic 45 willlight up. Graphic 45 will indicate to the caregiver that the patientshould be checked for a pulse or other signs of circulation asrecommended by the AHA for lay rescuers (step 120).

After a suitable interval (e.g., 5 to 7 seconds since audio prompt 118),the defibrillator will give an audio prompt indicating that thecaregiver should attach electrode assembly 16 to the patient (audioprompt 122), the LED adjacent graphic 45 will turn off, and the LEDadjacent graphic 46 will light up. Graphic 46 will indicate to thecaregiver how the electrode assembly 16 should be positioned on thepatient's chest (step 124).

At this point, the LED adjacent graphic 47 will light up, and thedefibrillator will give an audio prompt indicating that the patient'sheart rhythm is being analyzed by the defibrillator and the caregivershould stand clear (audio prompt 126). While this LED is lit, thedefibrillator will acquire ECG data from the electrode assembly, andanalyze the data to determine whether the patient's heart rhythm isshockable. This analysis is conventionally performed by AEDs.

If the defibrillator determines that the patient's heart rhythm is notshockable, the defibrillator will give an audio prompt such as “No shockadvised” (audio prompt 128). The LEDs next to graphics 48 and 49 willthen light up, and the defibrillator will give an audio promptindicating that the caregiver should again open the patient's airway,check for breathing and a pulse, and, if no pulse is detected by thecaregiver, then commence giving CPR (audio prompt 130, step 132).Graphics 48 and 49 will remind the caregiver of the appropriate steps toperform when giving CPR.

Alternatively, if the defibrillator determines that the patient's heartrhythm is shockable, the defibrillator will give an audio prompt such as“Shock advised. Stand clear of patient. Press treatment button” (audioprompt 134). At the same time, the heart and/or hand will light up,indicating to the caregiver the location of the treatment button. Atthis point, the caregiver will stand clear (and warn others, if present,to stand clear) and will press the heart, depressing the treatmentbutton and administering a defibrillating shock (or a series of shocks,as determined by the defibrillator electronics) to the patient (step136).

After step 136 has been performed, the defibrillator will automaticallyreanalyze the patient's heart rhythm, during which audio prompt 126 willagain be given and graphic 47 will again be illuminated. The analyze andshock sequence described above will be repeated up to three times if ashockable rhythm is repeatedly detected or until the defibrillator isturned off or the electrodes are removed. After the third shock has beendelivered, the device will illuminate LEDs 48 and 49 and issue the audioprompts 130/132. The device will keep LEDs 48 and 49 illuminated for aperiod of approximately one minute indicating that if CPR is performed,it should be continued for the entire minute. “Continue CPR” audioprompts may be repeated every 15-20 seconds during this period toinstruct the user to continue performing chest compressions and rescuebreathing.

After approximately one minute has elapsed, the device will extinguishLEDs 48 and 49 and illuminate LED 47. Audio prompt 126 (stand clear,analyzing rhythm) will also be issued and a new sequence of up to threeECG analyses/shocks will begin.

If the caregiver detects circulation during step 132, the caregiver mayturn off the defibrillator and/or remove the electrodes. Alternatively,the caregiver may not perform further CPR, but nonetheless allow thedevice to reanalyze the ECG after each one minute CPR period in order toprovide repeated periodic monitoring to ensure the patient continues tohave a non-shockable rhythm.

Thus, in the continuing presence of a shockable rhythm, the sequence ofthree ECG analyses and three shocks, followed by one minute of CPR, willcontinue indefinitely. If, instead, a non-shockable rhythm is or becomespresent, the sequence will be analyze/no shock advised, one minute ofCPR, analyze/no shock advised, one minute of CPR, etc. When a shock iseffective in converting the patient's heart rhythm to a heart rhythmthat does not require further defibrillating treatment, the sequencewill be: analyze/shock advised, shock (saves patient), analyze/no shockadvised, one minute CPR period (if pulse is detected then caregiver willnot do CPR during this period), analyze/no shock advised, one minute CPRperiod, etc., continuing until the caregiver turns the defibrillator(e.g., if the caregiver detects a pulse) or the electrodes are removed.

If electrode contact is lost at any time (as determined by the impedancedata received from the electrode assembly), this will result in anappropriate audio prompt, such as “check electrodes” and illumination ofthe LED adjacent graphic 46. The electrodes 208 may be stored in a well222 (FIG. 14) that is structurally integrated with the housing 14 or maybe a separate pouch 16.

It has also been discovered that a not-insignificant portion ofcaregivers are unable to open the packaging for the electrodes;therefore, a sensor may be provided to determine if the electrodepackage has been opened. If detection of the electrode package 16opening has not occurred within a predetermined period of time, the unitwill provide more detailed instructions to assist the user in openingthe packaging 16.

Referring to FIGS. 12 and 13, in preferred implementations, a means isprovided of detecting and differentiating successful completion ofmultiple steps of electrode application: (1) taking the electrodes 208out of the storage area 222 or pouch 16; (2) peeling the left pad 212from the liner 216; (3) peeling the right pad 214 from the liner 216;(4) applying the left pad 212 to the patient 218; and (5) applying theright pad 214 to the patient 218. Referring to FIGS. 12 and 13, apackage photo-sensor 210 is provided on the outer face of the electrodebacking 220. Detection that the electrode 208 is sealed in the storagearea is determined by the photo-sensor output being below a threshold. Aphoto-emitter/photo-sensor (PEPS) 223 combination is embedded into eachelectrode facing towards the liners 216. The liner 216 is constructed sothat a highly reflective aluminized Mylar, self-adhesive disk 224 isapplied to the liner 216 in the location directly beneath the PEPS 223.The reflective disk 224 is coated with a silicone release material onthe side in contact with the electrode 208 so that it remains in placewhen the electrode 208 is removed from the liner. In such aconfiguration, the processor is fully capable of differentiatingsubstantially the exact step in the protocol related to electrodeapplication. When the package photo-sensor 210 detects light above acertain threshold, it is known that the electrodes have been removedfrom the storage area 222 or pouch 16. The high reflectance area 224beneath each PEPS 223 provides a signal that is both a high intensity aswell as being synchronous with the emitter drive with low backgroundlevel; thus it is possible to distinguish with a high degree of accuracywhich, if either, of the electrodes 212, 214 is still applied to theliner 216. When an electrode 212, 214 is removed from the liner 216 thebackground level of the signal increases due to ambient light while thesynchronous portion decreases because there is little if any of thephoto-emitter light reflected back into the photo-sensor; this conditiondescribes when an electrode 212, 214 is removed from the liner 216. Whenit has been determined that an electrode 212, 214 has been removed fromthe liner 216, the processor means 20 proceeds to the next state—lookingfor application of that electrode to the patient. Application of theelectrode 212, 214 to the patient will result in a decrease in thebackground level of the signal output and some synchronous output levelintermediate to the synchronous level measured when the electrode 212,214 was still on the liner 216. If it has been determined that bothelectrodes 212, 214 are applied to the patient 218 but there is animpedance measured between the electrodes that is significantly outsidethe normal physiological range then it is very possible that the userhas applied the electrodes to the patient without removing the patient'sshirt. Surprisingly, this is not uncommon in real situations with users;a patient's shirt will have been only partially removed when electrodesare applied resulting in insufficient electrical contact with thepatient's skin. FIG. 6d shows the flowchart for prompting related toretrieval and application of electrodes. As in the case with respondingto a user's interactions.

Many other implementations are within the scope of the following claims.

For example, the graphics on the center decal can be accompanied by anydesired light source. For instance, if desired, all of the graphics canbe translucent, and can be backlit. Alternatively, the graphics can beprovided in the form of LED images, rather than on a decal.

While the electrodes have been illustrated in the form of an integralelectrode assembly, separate electrodes may be used.

In some implementations, generally all of the graphically illustratedsteps are shown at the same time, e.g., as illustrated by the decaldescribed above. This arrangement allows the caregiver to see the stepsthat will be performed next and thus anticipate the next step and beginit early if possible. However, alternatively, the graphics can bedisplayed one at a time, e.g., by using a screen that displays onegraphic at a time or backlit graphics that are unreadable when not backlit. This arrangement may in some cases avoid overwhelming novice or layrescuers, because it does not present the caregiver with too muchinformation all at the same time.

If desired, each graphic could have an associated button that, whenpressed, causes more detailed audio prompts related to that graphic tobe output by the defibrillator.

The cover 12 of the AED may include a decal on its underside, e.g.,decal 200 shown in FIG. 11. Decal 200 illustrates the use of the coveras a passive airway support device, to keep the patient's airway openduring resuscitation. Graphic 202 prompts the caregiver to roll thepatient over and place cover 12 under the patient's shoulders, andgraphic 204 illustrates the proper positioning of the cover 12 under thepatient to ensure an open airway.

While such a graphic is not included in the decal shown in FIG. 5, thedecal 40 may include a graphic that would prompt the user to check tosee if the patient is breathing. Such a graphic may include, e.g., apicture of the caregiver with his ear next to the patient's mouth. Thegraphic may also include lines indicating flow of air from the patient'smouth.

“Illuminated”, “light up”, and similar terms are used herein to refer toboth a steady light and a light of varying intensity (e.g., blinking). Ablinking light may be used, if desired, to more clearly draw the user'sattention to the associated graphic.

Referring to FIG. 16, in other implementations, a home first aid devicemay be provided for providing instructions and therapy, as needed, for avariety of medical situations. In some implementations, the device wouldinclude: (a) a cover to the device whose removal the processor iscapable of detecting; (b) a series of bound pages 230 on the face of thedevice under the cover 12 with a detection means providing fordetermining to which page the bound pages have been turned; (c) aprocessor; (d) a speaker 232 providing audio output. The home first aiddevice may also include a portion of the device used specifically forstorage of items commonly used in the course of providing aid such asbandaids, bandages, splints, antiseptic, etc. The storage areapreferably takes the form of a partitioned tray 234. Alternatively, thestorage area may take the form of multiple pockets, pouches, straps, orslots. The storage area is partitioned into individual wells in whicheach of the items is stored. Photoelectric sensors 236, 237 may beprovided in each of the wells, thereby providing a means of determiningwhich, if any, of the items has been removed by the user. Detectingwhich page the bound pages are turned to may be provided by embeddingsmall high magnetic intensity samarium cobalt magnets 240 in locationsspecific to each page. In some implementations, the magnets 240 arelocated along the bound edge of the pages, outside the printed area ofthe pages. Magnetic sensors 241 are located in the device housing 14that correspond to the locations where the magnets 240 located in thespecific pages make contact when the specific page is turned. Themagnetic sensor 241 may be a semiconductor device employing the Halleffect principle, but may also be a reed switch or other magneticallyactivated switch. By providing a means of detecting user actionsautomatically such as the detection of which page the user has turned toor which first aid item has been removed from the storage container, thedevice is able to interact and respond to the rescuer in an invisiblemanner, improving both speed as well as compliance to instructions. Insuch a manner, interactivity is preserved while at the same timeproviding a printed graphical interface to the user.

1. (canceled)
 2. An automated external defibrillator (AED) comprising: ahousing comprising a lid; printed graphical instructions indicatingsequential steps for treatment of a patient with the AED; a speakerconfigured to provide audible messages associated at least in part withthe printed graphical instructions; and defibrillation electrodes storedunder the lid and configured for application during the treatment of thepatient according to steps comprising: a step of peeling a leftelectrode pad from a liner of the left electrode pad, a step of applyingthe left electrode pad to the patient, a step of peeling a rightelectrode pad from a liner of the right electrode pad, and a step ofapplying the right electrode pad to the patient.
 3. The AED of claim 2,wherein the defibrillation electrodes are stored under the lid in a wellthat is structurally integrated with the housing.
 4. The AED of claim 3,wherein the defibrillation electrodes comprise graphics that showcorrect electrode placement.
 5. The AED of claim 2, wherein at least oneof the printed graphical instructions is disposed on the lid.
 6. The AEDof claim 5, wherein the at least one of the printed graphicalinstructions is disposed on an underside of the lid.
 7. The AED of claim5, wherein at least two of the printed graphical instructions areviewable at a same time by a user of the AED.
 8. The AED of claim 2,wherein the printed graphical instructions indicate an order of thesequential steps.
 9. The AED of claim 2, wherein the printed graphicalinstructions comprise one or more of: an instruction to open the lid, aninstruction to expose a bare chest of the patient, and instructions toattach the defibrillation electrodes to the patient at particularlocations on a patient's chest.
 10. The AED of claim 2, wherein theaudible messages comprise one or more of: a prompt to remove clothingfrom a patient's chest, a prompt to attach the defibrillation electrodesto the patient's chest, a prompt to press the defibrillation electrodesfirmly on the patient's chest, a prompt to not touch the patient, anindication that the AED is analyzing a heart rhythm, a prompt to startcardiopulmonary resuscitation compressions, a prompt to push harder, anda message comprising shock delivery information.
 11. The AED of claim 2,comprising at least one pull tab configured to enable access to thedefibrillation electrodes.
 12. The AED of claim 11, wherein the at leastone pull tab is red.
 13. The AED of claim 11, wherein the at least onepull tab is associated with a directional arrow.
 14. The AED of claim11, wherein the at least one pull tab is associated with a sequentialstep number.
 15. The AED of claim 11, wherein the at least one pull tabis located at a corner of a defibrillation electrode packaging.